Preflight, Interrupted

We all get distracted sometimes, but we must learn to recognize when it happens and respond appropriately.

5

The airline industry long ago figured out that one of the most dangerous things in aviation is two pilots trying to fly the same airplane at the same time. One inevitable result of such an arrangement is that there are times when no one is flying, and one of the ways we know this is from the accident record. Airlines evolved the pilot-flying/pilot-not-flying concept to acknowledge this characteristic of crewed cockpits and established clear responsibilities for each pilot.

In single-pilot general aviation cockpits, however, we rarely have the discipline to carve out specific roles or tasks for a pilot-rated passenger, who probably is eager to help and/or demonstrate his/her skills to the pilot in command. This often means delegating tasks like untying the airplane or looking up a CTAF and getting the destination’s automated weather. When there’s a clear delineation of responsibilities, the pilot-rated passenger can be a huge asset to ensuring the flight’s safety and efficiency.

It’s still up to the PIC to ensure the flight’s safe outcome, though, and this often means double-checking anything the pilot-passenger does. It also means checking for things that didn’t get done.

History

On September 24, 2017, at about 1829 Central time, a Beech C35 Bonanza collided with terrain during an uncontrolled descent after takeoff from the Harrell Field Airport in Camden, Ark. The commercial pilot and the pilot-rated passenger were fatally injured; the airplane was destroyed. Daytime visual conditions prevailed.

The pilot/owner and the pilot-rated passenger had just added 27.35 gallons of fuel to the airplane and were taking off for the final flight of the day, back to the airplane’s base. One witness questioned why the airplane was not gaining altitude after takeoff. Another witness saw the airplane flying just above the treetops, begin a left turn, and then descend and crash. Security camera video from about a mile away recorded the airplane in a steep, left-turning dive just before it impacted the ground and caught fire. No evidence of an inflight fire was observed in the video.

Investigation

The airplane came to rest upright in a field on airport property about 172 feet east and 1000 feet south of the takeoff runway’s departure end. With one exception, all airplane components were contained in an area 33 feet long and 35 feet wide. The grass and bushes immediately surrounding the wreckage were burned.

Much of the wreckage was consumed by the post-crash fire. Examination revealed the landing gear was down and the flaps were fully retracted at ground impact. One propeller blade remained attached to the hub and was bent aft about 60 degrees beginning about eight inches outboard from the hub. The blade showed no signs of S-bending or chordwise scratches. The other propeller blade was broken at the hub mounting clamps and was bent aft about 10 degrees beginning about 12 inches from the hub. The blade showed chordwise scratches and leading-edge rubbing from midspan to the blade tip.

Flight control continuity was confirmed from the forward cabin area to all control surfaces. Many of the engine accessories were too fire-damaged to verify their pre-crash condition. Borescope examination of the engine cylinders revealed an exhaust valve was worn but functional. All spark plugs showed normal operational signatures. The primary fuel selector was disassembled and found to be in the right main fuel tank feed position. According to the POH, the fuel selector should be on the left main fuel tank for takeoff. For landing, the selector should be on the tank with the greatest amount of fuel.

At 1815, the departure airport’s automated weather observation station recorded calm winds and 10 miles of visibility in clear skies. Data recovered from a handheld GPS device showed the airplane reaching its maximum GPS altitude of 298 feet (about 170 feet agl) at 1828:52. According to the NTSB, “a relatively flat, open, grass-covered area extended for about 2323 ft in the takeoff direction from the accident site to the airport perimeter.”

That exception to all of the airplane’s components being at the accident site? The airplane’s left main fuel tank cap was found about 4500 feet south of the rest of the wreckage, on the left side of the runway at the 1000-foot marker. The locking lever was engaged, and the cap showed no fire or impact damage.

Probable Cause

The NTSB determined the probable cause(s) of this accident included: “The pilot’s improper decision to return to the runway instead of landing straight ahead when the engine lost power and his failure to maintain adequate airspeed while maneuvering for an emergency landing, which resulted in an exceedance of the airplane’s critical angle of attack and an aerodynamic stall. Contributing to the accident was the pilot’s failure to properly secure the left main fuel tank cap after refueling, which resulted in a loss of engine power due to fuel starvation during the takeoff climb.”

The NTSB added: “It is likely that the left main fuel tank cap was not secured after the airplane was refueled and fell off the airplane’s left wing onto the runway during the takeoff. Without the cap in place, fuel escaped from the left main fuel tank and subsequently starved the engine of fuel during the climb, resulting in the power loss. The pilot likely switched the fuel selector to the right main fuel tank in an attempt to restart the engine. When the pilot tried to turn back to the airport, he failed to maintain a safe airspeed, and the airplane exceeded its critical angle of attack and entered an aerodynamic stall.”

The NTSB’s scenario is a likely one, and we can imagine reacting in similar way to the situation. At that altitude, however, the apparent attempt to turn back to the airport simply wasn’t going to work—it would have been better to land straight ahead. And we’re rather impressed at the speed with which a fuel tank can be emptied when its cap is missing.

Although we’ll never know how and why the left main fuel cap wasn’t properly secured after refueling, it could have involved miscommunication between the two pilots or the pilot-rated passenger’s unfamiliarity with the cap itself. But it likely came down to an interruption in the pilot’s routine, and a failure to verify everything was secured after the refueling.

AIRCRAFT PROFILE: Beechcraft C35 Bonanza
Landing

OEM Engine: Continental E-185-11

Empty weight: 1650 lbs.

Max gross TO weight: 2700 lbs.

Typical cruise speed: 148 KTAS

STANDARD fuel capacity: 39 gal.

Service Ceiling: 18,000 feet

Range: 510 nm

Vso: 48 KIAS

Distractions During Preflight
According to the Flight Safety Foundation (FSF), “Interruptions and distractions often result in omitting an action and/or deviating from standard operating procedures (SOPs).” A task force assembled by the FSF to examine the impact of interruptions and distractions in the cockpit found that their primary impact was to “break the flow pattern of ongoing…activities (actions or communications)” including SOPs, normal checklists, communications and problem-solving activities. The FSF says to reestablish situational awareness, we must:

• Identify the task being performed previously;

• Ask when during that task you were interrupted;

• Decide what’s necessary to complete the task;

• Prioritize the steps required to complete the task;

• Plan the sequence for those steps; and

• Act.

FuelCapAndFlashlight

5 COMMENTS

  1. This happened to me. Same aircraft, distraction during preflight caused me to not lock the fuel cap door after fueling. After a 20 minute flight to reposition the plane we ran out of fuel on final, at night . We could not make the runway and we were above Houston with no options to land. Thank God that flipping the tank lever allowed the engine to restart and we made the pattern and landed. After that: I have a sterile preflight policy. No talking to the pilot from preflight until we reach altitude. I am surprised that this pilot did not manage to start the engine. Mine started on its own as soon as I switched tanks.

  2. I witnessed another Bonanza take off at KGOO several months ago. On rotation a huge white cloud enveloped the left wing. I first thought it was smoke but quickly realized it was fuel. The cloud was larger than the aircraft. After racing to the terminal to get them to warn the plane, we looked up and there was the Bonanza rolling to stop at the fuel island. He had done a 270 hairpin turn and landed downwind when he saw the problem. All safe – this time. Imagine if an ignition source had ignited that fuel cloud! Yes, an open tank can be sucked dry in an amazingly short time!

  3. I’m aware of a similar situation with a CAP C-182 where the pilot was training the observer/copilot and had him check the fuel in the left tank. The observer assumed the pilot would also want to check it, left the cap off, got distracted, and didn’t communicate that to the pilot. Fortunately they were in the traffic pattern at a nearby airport when the pilot noticed fuel streaming from the left wing. It took about 25 minutes to vent a full tank of fuel, and interestingly, with the fuel selector on Both, fuel was pulled from the right tank to the left, leaving the left tank almost full and the right nearly empty and resulting in some confusing fuel gauge indications.

  4. Here are some tips based on fifty years of flying experience that may make more sense.
    1. Do not allow Line Service to “Help” you with a pre-flight. Often they don’t know what they are doing with your aircraft, may not be pilots and may interrupt your flow.
    2. Do not allow others to be speaking to you during your pre-flight. This is much like the sterile cockpit rule. Passersby or others have a different agenda than the pilot doing his pre-flight and the temptation to engage in conversation is high. Once that engagement begins, the distraction also begins and the chance for missing something is increased.
    3. The checklist is helpful to look at even if you think your memory is perfect. Even if you just check what you have already done, it may remind you of something you did not.

  5. Thanks for this great article. While loading my baggage compartment in a C182 I was distracted by line crews and failed to lock the baggage door. Fortunately it popped open while I started my taxi and I was alerted by frantically waving ground personnel. Embarrassed as hell I taxied back and locked the door. I agree with the article. If you do get interrupted probably best to start over.

LEAVE A REPLY

Please enter your comment!
Please enter your name here